Set for Life Application Form

Policy Number: 41111660

Importance of Truthful Disclosure: It’s important that you provide truthful answers in the Application
Form. Concealment of any facts may cause FWD to deny a claim on this policy.

INDIVIDUAL PROPOSED OWNER AND INSURED INFORMATION

Full Name Mr BENEDICK JOHN SANCHEZ PALARPALAR

Gender Male

Date of Birth 08/20/1993

Marital Status Married

Country of Birth Philippines

Place of Birth Victorias

Nationality Filipino

Valid ID Driver's License

ID Number N0222319061

Expiry Date 08/20/2027

HDA Guinpanaan, Brgy 5 poblacion, Victorias, Negros Occidental,

Current Address
Philippines, 6119

Email Address palarpalarbenedickjohn@gmail.com

Primary Contact Number 63 9754001373

FWD will use your policy delivery mode and contact details to update and notify you in relation to your policy
such as payments, billings, annual statement, policy contract, and FWD mobile app credentials. It’s also
important to let us know when your contact details change in order for us to manage your account better.

Office, Entrepreneur and Sales Professional (other than specific

Occupation Group
service provider)

INDUSTRY (This is applicable for POs)

Do you own any interest in or are in any No
way affiliated, deal with or provide
services to any of the following: (a) shell
company, (b) junket, (c) unlicensed casino
/gambling business, (d) unlicensed money
lender/changer or remittance business, (e)
unlicensed virtual currencies issuer or
intermediaries, (f) shell bank, (g)
unlicensed bank, and/or (h) unregulated or
unregistered charities?

Ver No. 001-SPE (03/10/2023) Page 1 of 10

 Do you own any interest in or are in any No
way affiliated with any of the following: (a)
weaponry and armament industry, (b)
licensed casino/gambling business, (c)
licensed money service business, (d)
licensed virtual asset/currency providers,
(e) embassy and foreign consulate, (f)
quarrying, mining or logging, (g) dealers in
high value or precious goods/stones
/metals, (h) cash intensive business, (i)
registered charitable and non-profit
organization/foundations?

Annual Income Php600,000.00

Source of Funds Business

Purpose of Insurance Investment

Business/Employer’s Name Benedick peso net

HDA Guinpanaan, Brgy 5 poblacion, Victorias, Negros Occidental,

Business/Employer’s Address
Philippines, 6119

Digital
*Hard copies are available for a fee. If you wish to request for a hard
Policy Delivery Mode copy, contact your FWD financial advisor or reach out to our 24/7
Customer Connect at +632 8888 8388, CustomerConnect.ph@fwd.
com, or connect to our Live Chat via our chatbot at fwd.com.ph.

PLAN DETAILS
PLAN PAYMENT TERM SUM ASSURED ANNUAL PREMIUM

Set for Life 10 500,000.00 28,000.00

FWD HealthPro Lite - To age 60 10 500,000.00 13,095.00

FWD SafetyPro - To age 75 10 500,000.00 1,600.00

FWD SurePro for Insured 10 3,728.03 1,214.25

FUND ALLOCATION (Each fund should have minimum of 10%. Total Fund Allocation should equal to 100%)
FUND NAMES ALLOCATION (%)

FWD Global Good Peso ESG Fund 100.0

PAYMENT INFORMATION
Payment Mode Monthly

Initial Payment Mode Offline

Renewal Payment Method (*applicable for annual, semi-annual,

Auto Direct Debit Arrangement
quarterly and monthly)

BENEFICIARY DETAILS
Relationship Allocation
Date of to the of Type of
Full Name Gender Designation Trustee Name
Birth Proposed Benefits Beneficiary
Insured (%)

Ver No. 001-SPE (03/10/2023) Page 2 of 10

 FARAH
06/16/1994 Female Spouse 20 Primary Revocable
GONZALES

Additional Information
HDA Guinpanaan, Brgy 5 poblacion, Victorias, Negros Occidental, Philippines,
Current Address
6119

Country of Birth Philippines

Place of Birth Victorias

Nationality Filipino

Contact Information 63 9754001373

Email Address palarpalarbenedickjohn@gmail.com

Relationship Allocation
Date of to the of Type of
Full Name Gender Designation Trustee Name
Birth Proposed Benefits Beneficiary
Insured (%)

JEFFERSON FARAH
07/06/2014 Male Son 20 Primary Revocable
CABCA GONZALES

Additional Information
HDA Guinpanaan, Brgy 5 poblacion, Victorias, Negros Occidental, Philippines,
Current Address
6119

Country of Birth Philippines

Place of Birth Victorias

Nationality Filipino

Contact Information 63 9754001373

Email Address palarpalarbenedickjohn@gmail.com

Relationship Allocation
Date of to the of Type of
Full Name Gender Designation Trustee Name
Birth Proposed Benefits Beneficiary
Insured (%)

SHIELTIEL ERIS FARAH

04/20/2019 Female Daughter 20 Primary Revocable
PALARPALAR GONZALES

Additional Information
HDA Guinpanaan, Brgy 5 poblacion, Victorias, Negros Occidental, Philippines,
Current Address
6119

Country of Birth Philippines

Place of Birth Victorias

Nationality Filipino

Contact Information 63 9754001373

Email Address palarpalarbenedickjohn@gmail.com

Relationship Allocation
Date of to the of Type of
Full Name Gender Designation Trustee Name
Birth Proposed Benefits Beneficiary
Insured (%)

Ver No. 001-SPE (03/10/2023) Page 3 of 10

 JACK DANIEL FARAH
05/27/2023 Male Son 20 Primary Revocable
PALARPALAR GONZALES

Additional Information
HDA Guinpanaan, Brgy 5 poblacion, Victorias, Negros Occidental, Philippines,
Current Address
6119

Country of Birth Philippines

Place of Birth Victorias

Nationality Filipino

Contact Information 63 9754001373

Email Address palarpalarbenedickjohn@gmail.com

Relationship Allocation
Date of to the of Type of
Full Name Gender Designation Trustee Name
Birth Proposed Benefits Beneficiary
Insured (%)

MA. NIDA
04/22/1964 Female Mother 20 Primary Revocable
PALARPALAR

Additional Information
HDA Guinpanaan, Brgy 5 poblacion, Victorias, Negros Occidental, Philippines,
Current Address
6119

Country of Birth Philippines

Place of Birth Victorias

Nationality Filipino

Contact Information 63 9754001373

Email Address palarpalarbenedickjohn@gmail.com

Please note:
If the “Allocation of Benefits” is left blank, benefits will be shared equally between Beneficiaries of the same type.
If the “Type of Beneficiary” or “Designation” are left blank, the Beneficiary will be defined as “Primary” or “Revocable”
respectively.
FWD will require prior approval of all Beneficiaries designated as “Irrevocable” before processing any policy
transactions.
If there are no changes to the Beneficiary or his designation during the lifetime of the Proposed Insured, the designation
will automatically be deemed “Irrevocable”.
If a designated Beneficiary is a minor, a legally recognized guardian or trustee may be required to enact a policy
transaction or file a claim.
If designated beneficiary is a creditor, benefits will be limited to the outstanding loan, if any, at the time of claim.

OTHER DECLARATIONS
REPLACEMENT OF EXISTING POLICIES

Do you own any insurance policy with any existing insurance company that is still
No
inforce?

Do you own any insurance policy with any insurance company that has lapsed but can be
No
reinstated?

Will you change or replace any life insurance policy/ies you own with the one you are
No
applying for?

Ver No. 001-SPE (03/10/2023) Page 4 of 10

 Will premiums for the insurance you are applying for be paid by a policy loan or
No
surrender value from any existing policies?

REMINDERS: REPLACING an existing life insurance policy with a new one is usually disadvantageous as you may
lose financial benefits you have accumulated over the years, or you may not even be insurable on standard terms, or
you may be required to pay a higher premium in view of higher age. Thus, for your own benefit and interest, please
consult your present insurer before making a final decision. Hear from both sides and make a careful comparison.
You can then be sure that you are making a decision that is your best interest.

US TAX DECLARATION

Are you a citizen, taxpayer, passport holder or green card holder of the U.S. or
No
were you born in the U.S?

BENEFICIAL OWNER/PAYOR

Do you have a Beneficial Owner? No

Will the premiums for this policy be paid for by a person/entity other than the
Yes
policy owner?

PAYOR INFORMATION
Full Name Ms FARAH REYES GONZALES

Relationship to the Owner Spouse

Gender Female

Date of Birth 06/16/1994

Country of Birth Philippines

Place of Birth Victorias

Nationality Filipino

Valid ID Driver's License

ID Number D1117001367

Expiry Date 06/16/2026

HDA guinpana-an, Brgy. 5 Poblacion, Victorias, Negros Occidental,

Current Address
Philippines, 6119

Email Address palarpalarbenedickjohn@gmail.com

Primary Contact Number 63 9754001373

OFFICE, ENTREPRENEUR and SALES PROFESSIONAL (other than

Occupation Group
specific service provider)

Annual Income Php600,000.00

Source of Funds Business

Business/Employer’s Name Benedict Peso Net and Remittances

Industry/ Nature of Business Others

Reason for third party payment wife bank account

YOUR LIFESTYLE

Ver No. 001-SPE (03/10/2023) Page 5 of 10

 Proposed Insured

Please choose the best description of your smoking habits:

Non-smoker

Smoker

In the past 12 months, have you done any of the following extreme sports:
You do not need to tell us about one off activities if you are not planning to do it again in the next 12 months

Scuba diving deeper than 40 metres, cave or wreck diving

Private flying (including hangliding, paragliding)

Mountain climbing over 4,000 metres in altitude

Motor sports

Competitive boxing

Base jumping or cliff diving

None of these

Have you ever been active or intend to be active in politics as a candidate or in any other capacity?

Yes

No

YOUR HEALTH
Proposed Insured

What is your Height? 5 ft and 3 in OR 160.0 cm

What is your Weight? 198.0 lbs OR 90.0 kg

Have you ever had or received medical advice or treatment for:

Cancer or carcinoma in situ

Heart defect, heart valve condition or other heart condition

Hepatitis B or hepatitis C

Nephritis, nephrotic syndrome or chronic kidney disease

HIV infection or positive HIV test

Loss of hearing, loss of vision (other than vision corrected by prescription lens) or physical disability

None of these

Aside from what you've already told us, in the last 2 years, have you had any other condition(s) which resulted in:

Repeated consultations or follow-up with a doctor, specialist or hospital

Continuous medication or treatment for 14 days or more

None of these

Aside from what you've already told us, are you currently:

Planning or been advised to consult a doctor (aside from routine health check)

Undergoing or awaiting investigations, follow-up or treatment including surgery

None of these

Ver No. 001-SPE (03/10/2023) Page 6 of 10

 YOUR OCCUPATION
Proposed Insured

What best describes your occupation? (Please read the help text on the description of each occupation group)

OFFICE, ENTREPRENEUR and SALES PROFESSIONAL (other than specific service provider)

INDEPENDENT SERVICE PROVIDER

WITH MANUAL LABOR

SPECIAL CLASS OCCUPATIONS

NON WORKING

GOVERNMENT OFFICIAL (Elected or Appointed)

FWD'S HOME OFFICE ENDORSEMENTS AND SPECIAL INSTRUCTIONS

DECLARATIONS MADE BY PROPOSED OWNER

I UNDERSTAND AND CONFIRM THAT:

1. I read the Sales Illustration before applying for the policy and am fully informed about the product’s benefits
& charges and my obligations.

2. The information I have provided above and in any supporting documents or information (collectively defined
as this ‘Application Form’) are true and complete. I confirm that FWD may rely on the information I have
provided to process my Application Form and service my policy. I understand that providing inaccurate or
incomplete information may result in future policy benefits being denied.

3. In case of apparent errors or omissions in this Application Form, or if the policy cannot be issued based on
FWD’s underwriting guidelines, FWD may amend this Application Form in the FWD’s Home Office
Endorsement and Special Instructions and may issue the policy on the basis of such amendments. I
understand that my acceptance of the policy ratifies these amendments.

4. I understand that my policy contract will be delivered to me in electronic format, through FWD mobile app
and/or email. I understand that providing incorrect contact details (e.g. mobile number and email address)
may compromise the security and privacy of my data as my FWD mobile app credentials, digital contract and
other policy information will be sent to these contact details. I warrant that the contact details provided are
accurate and I undertake to immediately inform FWD if there are any changes to these information.

5. I agree that my policy contract is considered delivered on the date when FWD sent the contract to my email
or 10 days after the contract is made available to my FWD mobile app account and/or email, whichever is
earlier. I understand that I don't need a physical copy of the contract in making claims with FWD.

6. If the policy will replace any existing policies, I have read the Replacement of Existing Policies.

7. I may be subjected to HIV testing and/or a personal investigation for the purpose of underwriting this
application.

Ver No. 001-SPE (03/10/2023) Page 7 of 10

 8. In accordance with the Insurance Commission’s Circular Letter No. 2016-54, your medical information will be
uploaded to a Medical Information Database accessible to life insurance companies for the purpose of
enhancing risk assessment and preventing fraud. Once uploaded, all life insurance companies will only have
limited access to your information in order to protect your right to privacy in accordance with law. A copy of
Circular Letter No. 2016-54 may be accessed at the Insurance Commission’s website at www.insurance.gov.
ph.

9. I have fully disclosed all of my citizenships, tax status, residencies, relevant taxpayer identification numbers
and agree to notify FWD within thirty days of any changes to the above information. For the purposes of
ensuring continued compliance, FWD may request information and/or documents from me including
completed, executed and, if necessary, notarized tax declarations or forms.

10. The amounts invested in the policies have been declared to the relevant government and tax authorities
(within or outside the Philippines) and none were derived, directly or indirectly, from illegal activities, illegal
sources or tax evasion. I authorize FWD to withhold payment of any amounts due to myself, my beneficiaries,
claimants, assignees and/or payees if required by any relevant government or tax authorities (within or
outside the Philippines).

11. The benefits payable under the policy are linked to the performance of the Investment Funds that I have
elected to invest in. I understand that the value of those Investment Funds and therefore the policy value will
rise and fall. I confirm that my Fund Allocation Instruction above is based solely on my personal judgment.

12. I may cancel the policy by giving FWD written notice within 15 days from receipt of the policy. In this
situation, I will receive a refund equal to the value of my units plus applicable Premium Charges and
Insurance Charges.

13. FWD may require satisfactory evidence of insurability of the Proposed Insured prior to accepting any top-up
premiums

14. This Application is subject to the laws, regulations, and guidelines on Anti-Money Laundering (AML) and
Terrorism-Financing Prevention (TFP).

15. I understand that FWD must comply with the relevant customer due diligence (CDD) measures required by
the Anti-Money Laundering Act, as amended and relevant issuances. I agree that during the effectivity of the
policy, in case I failed to comply with the CDD requirements, FWD may apply the following:
a) Restrict the services available or prohibit any further transactions on the policy until full and
proper CDD have been successfully conducted; and
b) If letter a. above is unsuccessful, terminate the policy, which shall entitle me to receive the
unused portion of the premium or withdrawal value, whichever is applicable.

16. I agree to be bound by obligations set out in the relevant United Nations Security Council Resolutions relating
to the prevention and suppression of proliferation financing of weapons of destruction, including the freezing
and unfreezing actions and the prohibitions from conducting transactions with designated persons and
entities.

DATA PRIVACY AND CONSENT DECLARATION

By signing and submitting this Application Form to FWD, I expressly consent to the following:

Ver No. 001-SPE (03/10/2023) Page 8 of 10

 1. FWD may collect, use, and store the information provided in this Application Form and from Third Parties
(including, but not limited to, affiliates, partners, contracted service providers, medical/financial/insurance
institutions, government agencies and medical information sharing facilities) to process this application and
to service my policies. The information gathered may be shared with FWD’s third parties for purposes
consistent with which it was obtained. These information (including those which will be available during the
life of my policies) may further be processed and shared for underwriting, reinsurance, policy issuance and
administration, rewards processing, claims adjudication, data analytics, historical and scientific research,
profiling, risk management, enhancement of products and services, identity verification, protection against
fraud, and to comply with legal, regulatory, or contractual requirements. I acknowledge that in certain
instances, my information may be processed through automated means.

2. I authorize FWD to disclose my personal and financial information to any government or tax authority (within
or outside the Philippines) for the purposes of ensuring FWD’s continual compliance with applicable laws,
regulations, guidelines and good market practices. I also agree that FWD has the right to require any of my
beneficiaries, claimants, assignees and/or payees to:
a. provide FWD with their respective personal and financial information.
b. sign and submit such documents as FWD may reasonably require; and
c. authorize FWD to disclose such personal and financial information to relevant Philippine
and/or foreign government and/or tax authorities.

3. I understand that FWD reports to its parent company located in Hong Kong and Singapore and may engage
third-party service providers and partners who, in some instances, may be located outside the Philippines. As
necessary, my personal and policy information may be processed, shared, stored, and be subject to the laws
of these foreign jurisdictions. FWD and its affiliates, third-party service providers and partners shall protect
the confidentiality of my personal information in a manner consistent with data protection principles and
applicable laws and regulations.

4. FWD may contact me to request or clarify information to process this application, send me policy
information, and perform other relevant activities to service my policies.

5. To ensure FWD’s continued service where my servicing intermediary, agent or Financial Solutions Consultant
(FSC), is no longer connected with FWD, I authorize FWD to assign and inform me of my new servicing
intermediary, who shall have access to my data for purposes of serving my policy/ies.

6. I attest that the consent of the Policy Insured, Beneficial Owner (if any), Beneficiary/ies, Payor (if any) and all
other data subjects in this Application form were obtained by me for the processing of their information for
purposes listed above.

I expressly consent to the processing of my information as stated above

I wish to be informed on FWD's products, and other promotional information that I might be interested in.

Privacy Policy:
Your privacy is a priority for FWD. The Company keeps your personal information about you and the products and
services you have with us in confidence. For more information about our Privacy Policy, kindly visit our website at
https://www.fwd.com.ph/en/privacy-policy. You may also email our Data Protection Office at dataprotection.
ph@fwd.com for any privacy concerns related to your information provided to us.

Note: A separate Temporary Life Insurance Certificate form will be forwarded to you as soon as the Initial Modal Premium has been received

Ver No. 001-SPE (03/10/2023) Page 9 of 10

 Proposed Owner printed name and signature

Remote Selling- Email Confirmation

Mr BENEDICK JOHN SANCHEZ
PALARPALAR

Date of Signing: 10/10/2023

DECLARATIONS MADE BY FINANCIAL SOLUTIONS CONSULTANT

In signing below, I certify that:

I have fully answered any questions the Proposed Owner and/or the Proposed Insured asked in a language
which they understand.
I have acted under the direction and authority of the Proposed Owner.
The Proposed Owner and/or Proposed Insured (where appropriate) have signed this Application Form in our
presence.
I affirm the identity of the Proposed Owner and/or Proposed Insured; and
I have seen and verified the original copy of the identification documents submitted in connection with this
application for insurance.
I have verified the contact details of the Proposed Owner/Insured and confirm they are true and accurate as
of date. I undertake to immediately inform FWD of any changes to the Proposed Owner/Insured’s contact
details.

Name and signature of Financial Solutions

Consultant

Tiffany Cabrillos

Code: 91221857

Date of Signing: 10/10/2023

BANK INFORMATION:
BANK REFERROR CODE: SBC08418
BANK REFERROR:

Ver No. 001-SPE (03/10/2023) Page 10 of 10